Probiotics in the treatment of periodontal disease: A systematic review

Effects of Probiotic Therapy on Periodontal and Peri-implant Treatments: An Umbrella Review

INTRODUCTION

The effectiveness of nonsurgical periodontal treatment is related to patient- and tooth-related factors. To overcome the limitations of the conventional approach, probiotics are one of the adjunct therapies that have been studied.

OBJECTIVES

This umbrella review answered the focused question: in adult patients with periodontal diseases or peri-implant diseases, does the use of probiotic therapy as an adjuvant to nonsurgical periodontal treatment when compared with nonsurgical periodontal treatment alone affect treatment effectiveness and clinical disease parameters?

METHODS

A systematic electronic search to identify systematic reviews according to PICOS criteria, defined a priori, was used, and 5 electronic databases were searched (Medline, LILACS, Cochrane Central Registry of Controlled Trials, Google Scholar, and DANS EASY). Included systematic reviews were rated using quality assessment tools by 2 independent reviewers.

RESULTS

Thirty systematic reviews were identified evaluating the effectiveness of probiotics in periodontal and peri-implant disease treatment. A quantitative analysis of the results was not possible due to the high heterogeneity of clinical data. Seventeen of 31 reviews reported clinically relevant benefits of probiotic therapy as an adjuvant to scaling and root planning. Twenty-two reviews had a low risk of bias, 7 had a moderate risk, and 2 had a high risk.

CONCLUSION

The evidence from the available studies is conflicting, which means that no definitive conclusions can be made about the effectiveness of probiotic therapy as an adjuvant to nonsurgical periodontal treatment. High-quality primary research studies are needed that control for known confounding variables.

KNOWLEDGE TRANSFER STATEMENT

This umbrella review provides some evidence regarding the efficacy of probiotics as an adjunct to nonsurgical periodontal therapy, despite some equivocal findings. However, short-term probiotic use alongside therapy appears to be advantageous; there is currently no evidence supporting their long-term benefits. We have also identified that probiotic research is primarily constrained by its origins in gastrointestinal applications, resulting in a lack of approved probiotics for dental use. This review highlights the need for extensive clinical research to ascertain their effectiveness in the oral environment. Nevertheless, the utilization of probiotics alongside periodontal treatment seems safe, with no reported adverse effects in patients. Thus, further clinical validations in oral health care settings are crucial.

Effects of Probiotic Lactobacilli plantarum in Treatment of Experimentally Induced Periodontal Disease in Rabbits

The aim of this study was to evaluate the therapeutic effects of probiotic Lactobacillus plantarum in experimentally induced periodontal disease in rabbits. The incisor teeth of 24 rabbits were scaled under general anesthesia. Two weeks later, silk ligatures were placed at the gingival margin of the incisor teeth to induce periodontal disease. After confirming the presence of periodontal disease by periodontal probing four weeks later, incisor mucogingival flaps were created and gingival pocket lavage and debridement was performed. The rabbits were randomly divided into four groups. Group 1: Control; Group 2: Microencapsulated form of the probiotic; Group 3: Planktonic form of the probiotic; and Group 4: Biofilm form of the probiotic. The rabbits were euthanized eight weeks later, and gingival connective tissue and epithelium were resected for histopathological and histomorphometric evaluation. The results showed that the rate of epithelial regeneration was lower and bone regeneration was significantly higher in the treatment groups compared to the Control group. The highest level of bone regeneration was in Group 2 (Microencapsulated probiotic). There was no significant difference in bone regeneration observed between the biofilm and planktonic probiotic groups. This study showed that applying the probiotic Lactobacillus plantarum in microencapsulated form improved bone regeneration in experimentally induced periodontal disease in rabbits.

Periodontal and Peri-Implant Diagnosis: Current Evidence and Future Directions

Dentistry and periodontology in particular are constantly evolving in terms of both diagnostic and therapeutic tools [...].

Effect of adjuvant probiotic therapy (Lactobacillus reuteri) in the treatment of periodontitis associated with diabetes mellitus: clinical, controlled, and randomized study

OBJECTIVES

Subgingival instrumentation (SI) with probiotics may be a proposal for the treatment of periodontitis (P), for patients with type 2 diabetes mellitus (T2DM). The Lactobacillus reuteri probiotic as an adjunctive therapy in the treatment of P associated with T2DM was evaluated.

MATERIALS AND METHODS

Forty diabetic participants diagnosed with P (stage III and IV, grade B) were randomized into SI + Placebo (n = 20): subgingival instrumentation plus placebo lozenges and SI + Probi (n = 20): subgingival instrumentation plus probiotics. Probing depth (PD), gingival recession (GR), clinical attachment level (CAL), plaque index (PI), bleeding on probing (BoP), and PISA index were performed at baseline and 30, 90, and 180 days. Cytokine concentration in the gingival crevicular fluid, subgingival biofilm sample, and LDL and HDL subfractions were evaluated.

RESULTS

In the deep pockets, PD in SI + Probi showed increased values (p = 0.02) compared to SI + Placebo at 90 days. For CAL, SI + Probi showed increased values compared to SI + Placebo, with a significant difference at 30 days (p = 0.03), 90 days (p = 0.02), and 180 days (p = 0.04). At #PD ≥ 7 mm, SI + Probi had a more frequent number of sites (p = 0.03) compared to SI + Placebo only at baseline. For the PISA, SI + Probi showed a significant difference (p = 0.04) compared to SI + Placebo at 90 days. For cytokines, SI + Probi showed higher quantification than SI + Placebo for IL-10 (p < 0.001) at 90 days, IL-12 (p = 0.010) at 90 days, IL-1β (p = 0.035) at 90 days, and IL-8 (p = 0.003) at baseline. SI + Placebo showed higher quantification of IL-1β (p = 0.041) compared to SI + Probi only at 30 days. There was a reduction in all microbial complexes. SI + Probi improved LDL size (246.7 nm vs 260.4 nm; p < 0.001), while large HDL subfractions were reduced aft 180 days of treatment (24.0% vs 20.3%; p = 0.022) when compared with SI + Placebo; this response was dependent of probiotics (1.0 mg/dL vs - 6.2 mg/dL; p = 0.002).

CONCLUSION

Subgingival instrumentation improved the clinical periodontal parameters in patients with T2DM. The use of L. reuteri probiotics had no additional effects compared with the placebo; however, there was a positive effect on the lipoprotein subfraction.

CLINICAL RELEVANCE

Scientific rationale for study: subgingival instrumentation with probiotics may be a proposal for the treatment of periodontitis (P), especially for patients with type 2 diabetes mellitus (T2DM).

PRINCIPAL FINDINGS

the use of L. reuteri probiotics had no additional effects compared with the placebo; however, there was a positive effect on the lipoprotein subfraction.  Practical implications: L. reuteri as an adjunct to subgingival instrumentation may have significant therapeutic implications in dyslipidemia.

A comprehensive review of the application of probiotics and postbiotics in oral health

Oral diseases are among the most common diseases around the world that people usually suffer from during their lifetime. Tooth decay is a multifactorial disease, and the composition of oral microbiota is a critical factor in its development. Also, Streptococcus mutans is considered the most important caries-causing species. It is expected that probiotics, as they adjust the intestinal microbiota and reduce the number of pathogenic bacteria in the human intestine, can exert their health-giving effects, especially the anti-pathogenic effect, in the oral cavity, which is part of the human gastrointestinal tract. Therefore, numerous in vitro and in vivo studies have been conducted on the role of probiotics in the prevention of tooth decay. In this review, while investigating the effect of different strains of probiotics Lactobacillus and Bifidobacteria on oral diseases, including dental caries, candida yeast infections, periodontal diseases, and halitosis, we have also discussed postbiotics as novel non-living biological compounds derived from probiotics.

Probiotics in Periodontal and Peri-Implant Health Management: Biofilm Control, Dysbiosis Reversal, and Host Modulation

Periodontitis and peri-implantitis are microbially associated diseases of the tissues supporting the teeth and dental implants that are mediated by host inflammation and eventually lead to tooth and dental implant loss. Given the probiotics' role in biofilm control, dysbiosis reversal, and host modulation, their potential beneficial effects on the improvement of periodontitis and peri-implantitis have been recently investigated. Moreover, probiotics use has also been proposed in periodontal health management in patients undergoing fixed orthodontic therapy. Therefore, the present study aimed to review, considering the periodontal microbiome composition around teeth and dental implants in healthy and pathological conditions, the putative favorable effects of probiotics on gingivitis, periodontitis, and peri-implantitis. The secondary aim of the present narrative review was to synthesize the supporting evidence and proposed protocols for probiotics use as adjuncts in periodontitis and peri-implantitis treatment and the periodontal health management of orthodontic patients with fixed appliances. Contrasting findings from the literature may be due to the different methods, posology, and duration of probiotics prescriptions and due to the heterogeneous biological and clinical measurement methods employed. Thus, no definitive conclusions could be drawn about the effectiveness of probiotics in periodontal management, both in healthy and pathological conditions. Further studies are needed to validate probiotics for periodontal management and provide recommended protocols.

Diagnosis and Management of Furcation Lesions in Dogs - A Review

The furcation is the anatomic area where the roots divide on a multirooted tooth. Periodontal disease causing alveolar bone loss can lead to furcation lesions of various stages. Once furcation involvement has occurred, the area can be more difficult to clean or treat due to the complex anatomy and morphology of furcations. Teeth with short root trunks, longer tooth roots, and roots with wide furcation entrance areas/degrees of separation and wide root divergence are considered better candidates for long term maintenance. Dog teeth possess many of these advantageous anatomic features compared to human teeth. Treatment options for teeth with furcation lesions include: closed debridement, open debridement, furcation plasty, tunneling, partial tooth or root resection, root separation (hemisection or trisection), regenerative therapies, or exodontia. There are many factors to consider in determining treatment options. The favorable and unfavorable characteristics for maintenance of teeth with furcation lesions are summarized. Home care and ongoing professional care are important aspects of periodontal disease control for any patient. Studies of systemic and local antibiotic therapies in human patients have not demonstrated reduction of furcation stages, and probiotic effects at furcation sites have not been specifically examined. Human review studies show that most molar teeth once deemed "hopeless" due to stage 3 furcation lesions can be maintained for at least 5 to 15 years with supportive periodontal therapy. Similar long term studies in dogs are needed to improve the evidence-based management of canine patients with furcation lesions.

Novel Indigenous Probiotic Lactobacillus reuteri Strain Produces Anti-biofilm Reuterin against Pathogenic Periodontal Bacteria

OBJECTIVE

 The aim of this study was to evaluate the effect of reuterin produced by a novel probiotic strain of Lactobacillus reuteri against periodontal biofilms.

MATERIALS AND METHODS

 L. reuteri LC382415 (an indigenous Indonesian strain) was cultured in Man, Rogosa, and Sharpe (MRS) agar in anaerobic conditions for 24 hours. To isolate reuterin, L. reuteri was suspended in 300-mM glycerol in MRS broth and incubated under anaerobic conditions for 3 hours, and the supernatant fraction was filtered. The presence of reuterin was confirmed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), and its concentration was determined. The effect of reuterin on Porphyromonas gingivalis ATCC 33277 and T. denticola ATCC 35405 biofilms was evaluated using biofilm assays. Biofilms were formed by incubating bacteria in 96-well microplates for 48 hours. A dose-dependent experiment was performed with reuterin concentrations of 12.5, 25, 50, and 100 μg/mL on biofilms. The inhibitory effect was measured at 1, 3, 6, and 24 hours. The biofilm masses were measured at 490 nm. Statistical analysis was using one-way ANOVA.

RESULTS

 The SDS-PAGE assay confirmed the presence of reuterin (52 kDa) in the culture supernatant of the L. reuteri strain. Reuterin in a concentration as low as 12.5 μg/mL significantly inhibited single- and mixed-species biofilms (p < 0.05).

CONCLUSIONS

 This is the first study to demonstrate the promising effect of reuterin isolated from L. reuteri LC382415 against periodontal bacteria. Further studies are warranted to explore the mechanism of this active component.

What are microbiological effects of the adjunctive use of probiotics in the treatment of periodontal diseases? A systematic review

Probiotics have aroused great interest as an adjunctive treatment to periodontal therapy, due to the frequent colonisation by periodontopathogens after therapy. The aim of this systematic review was to analyse in the scientific literature, evidence of the microbiological effects of probiotics as an adjunct to periodontal therapy in the treatment of periodontal diseases (PD). Only randomised controlled trials (RCT), evaluating the microbiological effect of probiotics as an adjunct to periodontal therapy. The authors conducted a search in PubMed/MEDLINE, LILACS, ScienceDirect, Web of Science and Cochrane Library to identify articles published in English until February 2020. The quality of the studies was assessed using the JADAD scale and the risk of bias was assessed according to the Cochrane Collaboration assessment tool. Of the 265 articles potentially relevant to this review, 10 studies were included. The most frequently used probiotic bacteria were those of the genus Lactobacillus spp. and the time of administration of the probiotics was between 14 days to 3 months. Most studies have shown that the adjuvant use of probiotics reduces the total mean counts of gram-negative anaerobic species (Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola and Prevotella intermedia) and gram-negative coccobacillus (Aggregatibacter actinomycetemcomitans) of subgingival plaque samples. Probiotics adjuvant to periodontal therapy reduces periodontopathogenic species in a greater proportion, compared only to periodontal therapy. Especially the Lactobacillus reuteri strain, without combination with other strains, offered a greater reduction in pathogenic bacteria associated with greater destruction of periodontal tissues and deep periodontal pockets. Researchers should perform high-quality RCT, evaluating single strains without combinations, in order to observe the microbiological benefits as adjunctive treatment of PD.

Protective Action of L. salivarius SGL03 and Lactoferrin against COVID-19 Infections in Human Nasopharynx

In this study, we used live viral particles from oral secretions from 17 people infected with SARS-CoV-2 and from 17 healthy volunteers, which were plated on a suitable medium complete for all microorganisms and minimal for L.salivarius growth. Both types of media also contained an appropriately prepared vector system pGEM-5Zf (+) based on the lactose operon (beta-galactosidase system). Incubation was carried out on both types of media for 24 h with the addition of 200 μL of Salistat SGL03 solution in order to test its inhibitory effect on the coronavirus contained in the oral mucosa and nasopharynx, visible as light blue virus particles on the test plates, which gradually disappeared in the material collected from infected persons over time. Regardless of the conducted experiments, swabs were additionally taken from the nasopharynx of infected and healthy people after rinsing the throat and oral mucosa with Salistat SGL03. In both types of experiments, after 24 h of incubation on appropriate media with biological material, we did not find any virus particles. Results were also confirmed by MIC and MBC tests. Results prove that lactoferrin, as one of the ingredients of the preparation, is probably a factor that blocks the attachment of virus particles to the host cells, determining its anti-viral properties. The conducted preliminary experiments constitute a very promising model for further research on the anti-viral properties of the ingredients contained in the Salistat SGL03 dietary supplement.

The Influence of Diet on Oxidative Stress and Inflammation Induced by Bacterial Biofilms in the Human Oral Cavity

The article is a concise compendium of knowledge on the etiology of pathogenic microorganisms of all complexes causing oral diseases. The influence of particular components of the diet and the role of oxidative stress in periodontal diseases were described. The study investigated the bacteriostatic effect of the diet of adults in in vivo and in vitro tests on the formation of bacterial biofilms living in the subgingival plaque, causing diseases called periodontitis. If left untreated, periodontitis can damage the gums and alveolar bones. Anaerobic bacteria, called periopathogens or periodontopathogens, play a key role in the etiopathogenesis of periodontitis. The most important periopathogens of the oral microbiota are bacteria of all complexes, including the red complex. The obtained results suggest the possibility of using a specific diet in the prevention and treatment of periodontal diseases-already treated as a disease of civilization. The quoted article is an innovative compilation of knowledge on this subject and it can be a valuable source of knowledge for professional hygienists, dentists, peridontologists, dentistry students and anyone who cares about proper oral hygiene. The obtained results suggest the possibility of using this type of diet in the prophylaxis of the oral cavity in order to avoid periodontitis.

Impact of the Diet on the Formation of Oxidative Stress and Inflammation Induced by Bacterial Biofilm in the Oral Cavity

The diet is related to the diversity of bacteria in the oral cavity, and the less diverse microbiota of the oral cavity may favor the growth of pathogenic bacteria of all bacterial complexes. Literature data indicate that disturbances in the balance of the bacterial flora of the oral cavity seem to contribute to both oral diseases, including periodontitis, and systemic diseases. If left untreated, periodontitis can damage the gums and alveolar bones. Improper modern eating habits have an impact on the oral microbiome and the gut microbiome, which increase the risk of several chronic diseases, including inflammatory bowel disease, obesity, type 2 diabetes, cardiovascular disease and cancer. The subject of our consideration is the influence of the traditional diet on the formation of oxidative stress and inflammation caused by bacterial biofilm in the oral cavity. Through dental, biomedical and laboratory studies, we wanted to investigate the effect of individual nutrients contained in specific diets on the induction of oxidative stress inducing inflammation of the soft tissues in the oral cavity in the presence of residual supra- and subgingival biofilm. In our research we used different types of diets marked as W, T, B, F and noninvasively collected biological material in the form of bacterial inoculum from volunteers. The analyzed material was grown on complete and selective media against specific strains of all bacterial complexes. Additionally, the zones of growth inhibition were analyzed based on the disc diffusion method. The research was supplemented with dental and periodontological indicators. The research was supplemented by the application of molecular biology methods related to bacterial DNA isolation, PCR reactions and sequencing. Such selected methods constitute an ideal screening test for the analysis of oral bacterial microbiota. The obtained results suggest that certain types of diet can be an effective prophylaxis in the treatment of civilization diseases such as inflammation of the oral cavity along with periodontal tissues and gingival pockets.

Effect of Ligilactobacillus salivarius and Other Natural Components against Anaerobic Periodontal Bacteria

In this present study, the bacteriostatic effect of Salistat SGL03 and the Lactobacillus salivarius strain contained in it was investigated in adults in in vivo and in vitro tests on selected red complex bacteria living in the subgingival plaque, inducing a disease called periodontitis, i.e., chronic periodontitis. Untreated periodontitis can lead to the destruction of the gums, root cementum, periodontium, and alveolar bone. Anaerobic bacteria, called periopathogens or periodontopathogens, play a key role in the etiopathogenesis of periodontitis. The most important periopathogens of the oral microbiota are: Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola and others. Our hypothesis was verified by taking swabs of scrapings from the surface of the teeth of female hygienists (volunteers) on full and selective growth media for L. salivarius. The sizes of the zones of growth inhibition of periopathogens on the media were measured before (in vitro) and after consumption (in vivo) of Salistat SGL03, based on the disk diffusion method, which is one of the methods of testing antibiotic resistance and drug susceptibility of pathogenic microorganisms. Additionally, each of the periopathogens analyzed by the reduction inoculation method, was treated with L. salivarius contained in the SGL03 preparation and incubated together in Petri dishes. The bacteriostatic activity of SGL03 preparation in selected periopathogens was also analyzed using the minimum inhibition concentration (MIC) and minimum bactericidal concentration (MBC) tests. The obtained results suggest the possibility of using the Salistat SGL03 dietary supplement in the prophylaxis and support of the treatment of periodontitis-already treated as a civilization disease.

Do probiotics promote oral health during orthodontic treatment with fixed appliances? A systematic review

BACKGROUND

Treatment with fixed orthodontic appliances has been associated with significant biofilm accumulation, thus putting patients at a higher risk of oral health deterioration. The use of probiotics has been proposed to be useful in the prevention or treatment of oral pathologies such as caries and diseases of periodontal tissues. Our aim was to investigate the effects of probiotic use on inflammation of the gingival tissues and the decalcification of the enamel in patients being treated with fixed orthodontic appliances.

METHODS

We searched without restrictions 8 databases and performed hand searching until September 2019. We searched for randomized controlled trials (RCTs) evaluating whether individuals with fixed orthodontic appliances benefit from probiotic treatment in terms of the inflammation of the gingivae and decalcification of the enamel. Following the selection of studies and the extraction of pertinent data, we appraised the risk of bias and the confidence in the observed effects based on established methodologies.

RESULTS

From the final qualifying studies, three did not show any statistically significant effect on gingival inflammation after probiotic administration of up to 1 month. Similarly, non-significant differences were noted in another study regarding white spot lesions development (mean administration for 17 months). No adverse effects were reported and the level of evidence was considered moderate.

CONCLUSIONS

Supplementation of orthodontic patients with probiotics did not affect the development of inflammation in the gingivae and decalcification in the enamel. Additional RCTs, with longer intervention and follow-up periods, and involving different combinations of probiotic strains are required.

TRIAL REGISTRATION

PROSPERO (CRD42018118008).

A single-centre investigator-blinded randomised parallel group clinical trial to investigate the effect of probiotic strains Streptococcus salivarius M18 and Lactobacillus acidophilus on gingival health of paediatric patients undergoing treatment with fixed orthodontic appliances: study protocol

BACKGROUND

There is limited data on the beneficial effects of probiotics on the gingival health of patients undergoing treatment with fixed orthodontic appliances. This study aims to compare the effect of probiotic tablets combined with regular oral hygiene versus regular oral hygiene alone on gingival status in these patients. The effect of probiotic intake on plaque formation and salivary microbiome composition will be also assessed.

METHODS AND ANALYSIS

This is a 3 month single-centre, single blind (clinical and laboratory examiners), parallel group randomised controlled two arm superiority trial. Fifty paediatric patients attending the Postgraduate Orthodontic Clinic at the Hamdan Bin Mohammed College of Dental Medicine (HBMCDM), Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, United Arab Emirates, who meet the eligibility criteria will be recruited. Block randomisation with 1:1 allocation and concealment of allocation will be carried out. The treatment group will receive probiotic tablets containing Streptococcus salivarius M18 and Lactobacillus acidophilus together with regular oral hygiene versus the control group on regular oral hygiene alone. Clinical examination and collection of saliva for microbiome assay will be carried out at baseline and end of study. Self-reporting by patients will be used to document acceptability and adverse effects. Statistically significant decrease in gingival bleeding on probing in the treatment group will be classified as primary outcome of treatment success. Statistically significant reduction in Plaque Index, Gingival Index and shift in the composition of the oral microbiome in favour of beneficial bacteria are secondary outcomes indicative of efficacy of probiotic intake.

ETHICS AND DISSEMINATION

Ethical approval for the study has been granted by the HBMCDM, MBRU, Institutional Review Board (Reference #: MBRU-IRB-2018-015). Study findings will be disseminated via publication in peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ISRCTN95085398.

Exploring the Association between Alzheimer's Disease, Oral Health, Microbial Endocrinology and Nutrition

Longitudinal monitoring of patients suggests a causal link between chronic periodontitis and the development of Alzheimer’s disease (AD). However, the explanation of how periodontitis can lead to dementia remains unclear. A working hypothesis links extrinsic inflammation as a secondary cause of AD. This hypothesis suggests a compromised oral hygiene leads to a dysbiotic oral microbiome whereby Porphyromonas gingivalis, a keystone periodontal pathogen, with its companion species, orchestrates immune subversion in the host. Brushing and chewing on teeth supported by already injured soft tissues leads to bacteremias. As a result, a persistent systemic inflammatory response develops to periodontal pathogens. The pathogens, and the host’s inflammatory response, subsequently lead to the initiation and progression of multiple metabolic and inflammatory co-morbidities, including AD. Insufficient levels of essential micronutrients can lead to microbial dysbiosis through the growth of periodontal pathogens such as demonstrated for P. gingivalis under low hemin bioavailability. An individual’s diet also defines the consortium of microbial communities that take up residency in the oral and gastrointestinal (GI) tract microbiomes. Their imbalance can lead to behavioral changes. For example, probiotics enriched in Lactobacillus genus of bacteria, when ingested, exert some anti-inflammatory influence through common host/bacterial neurochemicals, both locally, and through sensory signaling back to the brain. Early life dietary behaviors may cause an imbalance in the host/microbial endocrinology through a dietary intake incompatible with a healthy GI tract microbiome later in life. This imbalance in host/microbial endocrinology may have a lasting impact on mental health. This observation opens up an opportunity to explore the mechanisms, which may underlie the previously detected relationship between diet, oral/GI microbial communities, to anxiety, cognition and sleep patterns. This review suggests healthy diet based interventions that together with improved life style/behavioral changes may reduce and/or delay the incidence of AD.